Powys Falls Care Pathway

1. Powys Falls Care Pathway What will happen to the person who falls in Powys

2. The U.K. has an ageing population The people aged over 65 is estimated by 2031 to exceed 16 billion (Jones 1994) Wales follows this trend with the number of people aged over 75 and especially over 85 increasing, of which 90% of these people live in their own homes (Jones 1994) The population of Powys has increased over the past 10 years by 5.5%, those people over 65 having increased by 1% and account for 20% of the total population ((Powys Census 2002) If this trend continues, in 2011 there will be 28,000 people in Powys over the age of 65

3. Patients with Fracture Neck of Femur 4,222 patients in Wales are admitted to hospital each year with a hip fracture, 139 in Powys for the year 2003-2004 Average patient stay is 35 days and they take up 25% of all Orthopaedic beds (Patient Episode Database for Wales 1997-1999) The total cost per patient being �20,000 (Torgerson et al 2001) The cost to Health and Social Services being �84 million per year 10% of people will die within a month of hip fracture 50% of survivors fail to regain their former independence (Clinical Performance Indicators for N.H.S.1999)

4. Who can refer to the District Nurses? Consultant General Practitioner Practice Nurse Physiotherapist Occupational therapist Podiatrist Hospital staff (if patient in for less than 72 hours) D.G.H. Accident and emergency departments Minor injury units Day hospital�s Ambulance service Family, carer�s and self

5. What happens then? The referral is sent to the District Nurse Team and they make telephone contact with the patient within 2 working days to arrange a mutually convienent appointment to undertake a Falls Care Pathway, with the patients consent. This is done in the patients own home or can be done at the surgery if the patient does not want a visit at home

6. Powys L.H.B. Falls Pack Falls clerking proforma (hospital use only) District Nurse referral form Falls care pathway Primary care fracture risk assessment tool Patient information leaflet for postural hypotension, footwear and how to maximize vision Physiotherapy referral form Occupational therapy referral form Podiatry referral form Powys care line leaflet Care and repair rapid response referral form Information leaflets on slips and trips, healthy bones and managing your medicines

7. Care Pathway An integrated care pathway determines locally agreed multi-disciplinary practice, based on guidelines and evidence where available, for a specific client/patient group. It forms all or part of the clinical records, documents the care given and facilitates the evaluation of outcomes for continuously quality monitoring.(Riley 1998)

8. Medical causes of Falls Loss of consciousness Palpitations Dizziness, light headedness, pale, sweaty Neck movements Relation to change in posture Known medical condition affecting gait and balance Medical review needed to consider:- Carotid sinus sensitivity, arrhythmia, Aortic stenosis, Postural hypotension. Benign positional vertigo Post prandial hypotension Epilepsy Selected patients may need 24 ECG, echo, carotid sinus sensitivity

9. Medication increasing the risk of falls 4 or more medications Sedatives and hypnotics Psychoactive drugs Neuroleptics Antihypertensives Opioid analgesics More than one unit of alcohol per day Medication review by G.P. or community pharmacist Question the need for sleeping tablets and psychoactive drugs Check blood pressure and review treatment Discuss alcohol intake

10. Postural Hypotension Lying b/p-patient has rested supine for 15 mins Systolic > 90 Standing immediately Standing after 2 mins >20 mm hg systolic >10 mm hg drop diastolic Consider medication Review medication doseage, time taken and compliance Teach to stabilize after changing position and before walking Consider patient information leaflet Consider G.P. review if problems persist ECG if pulse <60 or >100 or irregular

11. Impaired memory Clients age Date of birth Time of day Address for recall Name of institution Recognition of 2 persons Name of Prime Minister Name of Monarch Count backwards 20-1 Scoring 8-10 normal, 5-7 moderate, 0-4 severe Refer to CPN for memory clinic assessment and EMI services with patient consent Discuss strategy with family and carer�s regarding future falls Assess environmental hazards

12. Impaired gait and balance Ask patient to perform the �get up and go test� Does patient need help to get out of the chair Any dizziness/ unsteady Do they sit down safely Abnormal gait Time taken Mobility aid�s used Physiotherapy referral for assessment and evaluation G.P. referral if signs of undiagnosed Parkinson�s or neurological disorder Falls exercise/ prevention programme Re-enablement team Day hospital

13. Environmental hazards Poor and uneven lighting Slippery and/or uneven floors, loose rugs,carpets Raised door sills Obstructed walkways Shelves and cupboards too high or low Stairs/steps outside Pets Difficulties with transfers High non-glare lights, night light Non slip mats,removal of loose rugs, repair carpets Clear walkways O.T. referral for complex physical needs and/or a difficult environment Care and repair referral

14. High fracture risk Suffered a recent fragility fracture On oral corticosteriod therapy longer than 3 months Past history of hip, spine or wrist fracture Housebound Living in care Primary care fracture risk assessment tool - 7 or more high risk G.P. review to consider osteoporosis Lifestyle advise i.e alcohol, smoking, diet Osteoporosis screening bloods Consider calcium and vit. D supplements If over 65 with fragility fracture treat with Biphosphonate

15. Other considerations Footwear and feet problems Poor vision Alarm Raising Continence problems Podiatry referral if long thick toe nails, corns or ulcers Consider footwear Advise to see optician every 2 years Bifocals/Varifocals Strategy in place Community alarm Able to get up off the floor Continence pathway Refer to Continence nurse

16. Future recommendations Powys patient falls database Condensed format of Pathway on G.P. computer patient records system Falls prevention/exercise programmes throughout Powys Falls prevention clinics Increased resources to accommodate increased referrals from the pathway findings

17. If you require any further information and/or advice please contact:- Annie Evans District Nurse Team Leader Park Street Surgery Newtown Telephone. 01686 628837